Whsmp · OPW16/0021

                                                                                              Incident/Injury /Hazard Report Form
                                                                                                                                                    HB-HSEQ-F-027-B
                                                                                                                                                         Version: 11




TEAM LEADER:                                                                       JOB NUMBER:

TYPE OF INCIDENT – SELECT ONE INCIDENT TYPE FROM EITHER BOX 1 OR BOX 2
BOX 1 – INCIDENTS NOTIFIABLE TO THE STATE REGULATOR
     Fatality                                      Serious injury (select injury type from box 3)                  Dangerous incident

     Electrical Event                              Serious illness (select injury type from box 3


BOX 2 – NOT NOTIFIABLE INCIDENTS
     Report ONLY incident / injury            Near miss incident            Environmental                     Identified hazard          Not Work Related

BOX 3 - SELECT 1 ONLY INJURY ILLNESS TYPE – REFER TO INJURY CLASSIFICATION GUIDELINES HB-HSEQ-G-027
     Lost Time Injury (LTI)                                                    Restricted Work Injury (RWI)

     Medical Treatment Injury (MTI)                                            First Aid Injury (FAI)

HUTCHINSON BUILDERS PROJECT DETAILS
      Workplace or Project

                Site Address

INJURED / INVOLVED PARTY DETAILS (if applicable)
Is the Injured Party / Person involved a Hutchinson Builders Apprentice or GSCS Student?                                   Yes                         No
                   Surname                                                             Given Name(s)

          Contact Address

          Contact Number                                                                            D.O.B.

            Employed by:         HUTCHINSON BUILDERS                                            SUBCONTRACTOR
       (Complete relevant)       Region:                                                        Name:

                   Address:



INCIDENT / HAZARD / ENV IMPACT DETAILS
     Time of Incident etc.:                                       Date

   Time Incident Reported                                     Reported                                                  Reported
                                                                   By:                                                      To::
     Location of Incident /
                    hazard
         (I.e. where on site?)
          Brief description




           Nature of Injury              NO INJURY       Fractures        Concussion          Contusion            Foreign Body       Dislocation

                                         Laceration       Burn        Amputation           Sprain            Abrasion        Strain     Multiple

           Bodily Location




ALL fields are to be completed prior to closing out the incident.                                                                                     Page 1 of 3